MCOL Blog

by Laurie Gelb, July 28, 2010

Health care surveys still ask “analog questions” in a digital world, limiting the impact of disease management, marketing initiatives and even transactional communiqués like EOBs. Besides evoking “socially acceptable” responses (who wouldn’t want to be healthily skeptical and savvy, unless you wanted to be stubborn and oppositional?), surveys in 2010 often still rest on “service as product” and “product = attribute bundle” paradigms, which apply poorly to medicine.

As interventions move into the social and mobile media, the risk of pouring more money and brand equity into misguided action increases. In fact, adding to “stimulus overload” can hasten patient and caregiver denial, apathy, fatalism, overkill – and it’s ever-easier to tell everyone in their social networks how and why they got to that point.

Health care realities that are often overlooked by forced choice (e.g. A vs. B scenarios, point allocations, rankings) and attribute-based questions include:

• N=1. No two patients have exactly the same personal/family histories and environments. Yet we ask everyone the same questions. Why? We have computers now so we can personalize questionnaires in real time, the same way we say we want to personalize interventions.

• Heuristics – shortcuts – are more necessary to making health choices than any other kind. You may be able to consider all the possible routes to work in the morning, but you can’t consider – ever—all the supplements you could be taking.

• Opportunities to re-evaluate choices like daily dosing, glucose monitoring, diet, exercise are infinite– unlike  the dishwasher that you’re basically stuck with for a few years

• Instability/unpredictability of product “attributes” – we don’t all define “effectiveness” the same way, yet we all know what “four bedrooms” means, and the drug you took with no issues yesterday can land you in ER today.

• Inability to create what everyone knows would be the ideal product (want a vitamin water that melts solid tumors?), unlike, say, the cereal industry (Apple Jacks with 12g sugar/serving)

• No single “health personality.” For me, popping a naproxen is nothing; for my son, it’s agonizing. Yet he’s blasé enough to have visited a chiro, whereas I never will. So if you ask the two of us the same questions about beliefs and recent care, you’ll miss why our choices differ.

• In for a penny, in for a pound. A plumber can unclog the kitchen sink with no effect on the bathroom, whereas treatment focused on one system often adversely affects another. And when weighing the zero-sum game of deductibles, co-pays and OOP limits, it’s easy to feel that there are no good choices.

By replacing traditional questionnaires with decision-centered designs in which no two respondents may see exactly the same questions, we can understand and track what our audiences believe they know and the extent to which these beliefs are associated with their choices. With dynamic surveys, domains, measures and thresholds are not pre-established but are provided to us by respondents (with whom we are conversing, not forcing them to abstract something that is very real). This on-the-ground data enables us to better address knowledge gaps, evolving expectations, epidemiology/behavior, barriers to action and more – often with interactive tools. Moreover, patient, clinician and payor thresholds often differ significantly, creating misaligned incentives. When we understand how these differ, we can realign programs for “win/win/win” scenarios that optimize health outcomes.

by Clive Riddle, July 22, 2010

The American College of Obstetricians and Gynecologists have just issued new guidelines for a vaginal birth after cesarean (VBAC).  Doctor Richard Waldman, president of The College tells us, "the current cesarean rate is undeniably high and absolutely concerns us as ob-gyns. These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."

Doctor Waldman adds, “Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women's access to VBAC." The VBAC rate has dropped dramatically during the past 15 years, due to “restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.”

What has changed? The College guidelines now state women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a trial of labor after cesarean (TOLAC).Proactive counseling is being emphasized, whereby “physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complications from a trial of labor, all viewed in the context of her future reproductive plans.” They state that women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. The College says that restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center. The new guidelines, Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is available in the August 2010 issue of Obstetrics & Gynecology.

Here’s three statistical items supplied by the College:

• U.S. Cesarean delivery rate: 5% in 1970; 31% in 2007.
• U.S. VBAC rate:  5% in 1985; 28% in 1996, 8.5% in  2006
• Risk of uterine rupture during a TOLAC: —between 0.5% and 0.9%

By Clive Riddle, July 14, 2010

JAMA’s current issue features the article: Physicians' Perceptions, Preparedness for reporting, and Experiences Related to Impaired and Incompetent Colleagues, by Catherine M. DesRoches, DrPH et.al. [JAMA. 2010;304(2):187-193. doi:10.1001/jama.2010.921]. The article presents survey results regarding physician peer monitoring and reporting, which nationally polled “2938 eligible physicians practicing in the United States in 2009 in anesthesiology, cardiology, family practice, general surgery, internal medicine, pediatrics, and psychiatry. Overall, 1891 physicians (64.4%) responded.”

The survey asked "In the last three years, have you had direct, personal knowledge of a physician who was impaired or incompetent to practice medicine in your hospital, group, or practice?" The study found that:

• 64% agreed with the professional commitment to report physicians who are significantly impaired or otherwise incompetent to practice.
• 69% said they were prepared to effectively deal with and report impaired colleagues in their medical practice
• 36% do not feel obligated by professional commitment to report such physicians
• 17% had direct personal knowledge of a physician colleague who was incompetent to practice medicine in their hospital, group, or practice.
• Of the 17% with this knowledge, 67% reported this colleague to the relevant authority.
• Physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.
• Pediatricians and family practice physicians were the least likely to say they felt prepared to deal such colleagues; anesthesiologist and psychologists apparently felt most prepared
• Most cited reasons for taking no action was (1) belief that someone else was taking care of the problem (19%) belief that nothing would happen as a result of the report (15%) and fear of retribution (12%)

The study concluded that “physicians support the professional commitment to report all instances of impaired or incompetent colleagues in their medical practice to a relevant authority; however, when faced with these situations, many do not report” " Matthew Wynia, director of the AMA Institute for Ethics, comments that “I don't think there's any excuse for less than 100 percent of physicians holding true to these ideals." A free JAMA podcast by JAMA’s editor in chief discussing the survey as part of commentary on the current issue is available for download.

Headlines regarding the article accentuate the minority percentage of physicians who do not report:

Los Angeles Times:  Study shows doctors often eschew watchdog role

CBS News:  Many Docs Don't Blow Whistle On Colleagues

The Washington Post:  Do doctors rat on each other?

This is certainly not the first study to address the issue of physician peer review. Some recent examples include California’s legislatively mandated study, which was released by sub-contractor Lumetra as the Comprehensive Study of Peer Review in California: Final Report, July 31, 2008 which found it was “apparent is that the present peer review system is broken for various reasons and is in need of a major fix”; from Public Citizen-  Hospitals Drop the Ball on Physician Oversight , released May 27, 2009 which concluded a “lack of detection and widespread under-reporting to the National Practitioner Data Bank raise serious questions about hospital peer review.” Modern Physician magazine, in their June 8, 2009 issue ran a lengthy article discussing the debate about the Public Citizen report .

Here’s a few observations for consideration on this issue:

• Regulated peer review focuses on the hospital setting, and is built on a 20^th century model in which a greater degree of care was delivered in a hospital setting. Physician behavior and actions outside the hospital setting are typically under-addressed by state or federal regulations
• Physicians, excel as they do as a profession, are still human, and subject to similar mindsets, pressures and workplace issues as other professions. Who really thinks any other profession subject to peer review would have better reporting outcomes?
• Accountability for professional competence in any profession is much stronger when there is an organization structure that the professional is employed by, or financially belongs to. Organization accountability can be an even stronger continuous force for some than regulatory or even ethical accountability.  Thus large medical groups, medical schools, VA, group health plans and other such entities tend to have less of a problem in this area than open medical staffs. Note the survey findings that “physicians working in hospitals or medical schools; and physicians with l0 years or fewer experience, were most likely to report impaired or incompetent colleagues.” As younger physicians have a greater tendency to practice in larger medical groups and organizations, this issue should experience improvement over time.

by Claire Thayer, July 9, 2010

The Managed Care On-Line LinkedIn Group provides member networking, discussions and other resources, with the comfort of knowing that all members of the Group are professionals affiliated exclusively through their MCOL membership. Join over 1,138 MCOL Members! Use the LinkedIn tools to start a discussion, connect with other MCOL Members, view member profiles and more! To participate, go to: http://www.linkedin.com/groups?gid=1425447&sharedKey=3C47E8585289

by Claire Thayer, July 2, 2010

MCOL’s Healthcare Web Summit announces a new complimentary webinar event sponsored by MEDai: The Power of Data & Applied Clinical Analytics: Achieving Success in a Transformed Healthcare System.  Please join us on Wednesday, September 1, 2010 at 1PM Eastern for a complimentary webinar event. Understanding how analytics can be leveraged across care settings to create a single truth around a patient’s health stat is the key to achieving meaningful use of health information technology and securing your place in the new healthcare model.  Detailed information at: http://www.healthwebsummit.com/medai090110.htm